MacCullough, Loneta NEW YORK STATE DEPARTMENT OF HEALTH " It 2 b c
Vital Records Section Burial - Transit Permit
` Name First eir fiddle Last S"7
:::::: Date /�
t If Veteran .S. Armed = e ,
D ea Age 9
V- �!1 / War or Dates
Place o h Hospital, Institution or
• i�✓��/�• lei—,City wn Villag Street Address YZ �•
Manner of Death Natural Cause Ei Accident El Homicide Suicide Undetermined Pending
Circumstances Investigation
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Medical Certifier Name Title
R h Ar ,
Address z�� ......)4(00„..xio (:::9. y
`' Deat e "cate Filed &..° District Number Register Number
iiii Ci To r Village (' 37 S-
Date Cema'j or Cr tory //
❑Burial " / -' S/-3 /_...C--n-ll-J VCl.� .0 -eQ---/'n
Address
Cremation
gDate Place Removed
0❑Removal and/or Held
and/or Address
Hold
p Date Point of
03 r-iQ Transportation Shipment
5 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to / Registration Number
:'- Name of Funeral Home �� ��le- )r / D�� ci/&e
Address
/ it= / `Yz'-,CJ iC-�1 /o7 d T
<3 Name of Funeral Firm Makin i "osi ion or o hom
Remains are Shipped, If Other than Above
Address
<� Permission is hereby granted to dispose of the human rem ins described abo e s in ' ted.
•`• Date Issued /SAD/3 Registrar of Vital Statistics ,_,/ v te,'r-4-4-a--
(s re)
— Place /C ' ""` - i
a _District Number___ Z
P 7
I certify that the remains of the decedent identified above were dis osed of in accordance with this permit on:
i;;' fo{'' �
Date of Disposition siIl i� _ Place of Disposition '4+a r'""r '�
2 (address)
LU
CC (section) of number) grave number)
A Name of Sexton or Pers n in Charge o Premises c Jrf
a"i''�
Z (please print)
: Signature Title (Ep.16TO
(over)
DOH-1555 (9/98)